Myocarditis With Cardiogenic Shock in a Young Female With Severe Ulcerative Colitis Flare.

Myocarditis is a rare extraintestinal manifestation of inflammatory bowel disease. Myopericarditis-associated inflammatory bowel disease can be a side effect of the medications used to treat inflammatory bowel disease or the disease process. We present a 25-year-old female with history of ulcerative colitis presented with abdominal pain associated with sharp and central chest pain. She was in a flare of ulcerative colitis with bloody diarrhea. She developed shock and was in intensive care unit. Echocardiogram showed reduced ejection fraction and pericardial effusion. Coronary artery disease, sepsis, thyroid disease were ruled out. She was treated with systemic antibiotics, intravenous steroids, and guideline-directed medical therapy for presumed ulerative colitis associated with myopericarditis and had symptomatic improvement. Treatment of IBD-associated myopericarditis includes the standard induction treatment for IBD with steroids and guideline-directed medical therapy for heart failure.

A Case of Candida Empyema in a Patient With Esophagopleural Fistula.

Fungal empyema is a rare entity, particularly in immunocompetent patients. It has been noted to occur in a patient with esophageal perforation. Esophageal perforation has a wide range of clinical presentations and associated complications depending on the size and site of perforation. Although the classic presentation of esophageal perforation, also known as Boerhaave syndrome, is often dramatic with hemodynamic instability and mediastinitis. Smaller perforations and esophageopleural fistula can lead to more indolent presentation in the form of complications such as necrotizing pneumonia and pleural effusions. Here we present a 42-year-old patient with alcohol withdrawal and aspiration pneumonia, later found to have loculated pleural effusions and empyema with pleural culture growing candida and staph Epidermidis. After his mental recovery, the initiation of oral feeding led to the discovery of esophageal perforation, further complicated by esophageopleural fistula formation. He had a prolonged hospital course but remained hemodynamically stable. He was treated with an esophageal stent and feeding tube placement, as well as antifungals for candida empyema.

Portal Vein Thrombosis Associated With Fusobacterium nucleatum Bacteremia: A Rare Abdominal Variant of Lemierre's Syndrome.

Lemierre's syndrome is a rare but potentially severe complication of bacterial infections that usually affects previously healthy adolescents and young adults. It commonly presents as septic thrombophlebitis of the internal jugular vein and bacteremia following a recent oropharyngeal infection. The most commonly isolated organisms are Fusobacterium necrophorum, followed by Fusobacterium nucleatum and other anaerobes. Atypical Lemierre's syndrome is characterized by thrombophlebitis at sites distant from the head and neck veins and is far less encountered than typical Lemierre's syndrome. Here, we present a case of an elderly African American female with pylephlebitis, a rare abdominal variant of Lemierre's syndrome with extensive portal vein, splenic vein, and mesenteric vein thrombosis following perforated diverticulitis and resultant F. nucleatum bacteremia. She demonstrated complete recovery following appropriate long-term intravenous antibiotics and anticoagulation. This case calls attention to the re-emergence of the rare manifestation of this forgotten disease and highlights improved outcomes with prompt recognition and early treatment.

Early Left Ventricular Thrombus Following Ventricular Fibrillation/Ventricular Tachycardia Electrical Storm.

Left ventricular thrombus (LVT) formation is a serious clinical complication of low-flow states that may be seen in an ischaemic, arrhythmic heart. While LVT formation has a poor prognosis, in the setting of myocardial infarction it is usually a result of post-infarct sequelae such as left ventricle aneurysms, and inflammatory changes from damaged tissue, with the LVT taking several days to form. Arrythmias such as ventricular tachycardia (VT) or ventricular fibrillation (VF) may also lead to thrombus formation, as they contribute to stasis due to decreased cardiac output. Large anterolateral myocardial infarctions can cause electrical or arrhythmic storm, characterized by more than three episodes of VT or VF in a 24-hour period. This prolonged state of dyskinesis further increases the risk of thrombosis, creating a compounding effect. Here, we report the case of a patient who had a VF cardiac arrest with electrical storm secondary to anterolateral myocardial infarction complicated with LVT formation found on echocardiogram after the cardiac arrest, which was absent on presentation. This thrombus formation occurred particularly early during the course of the patient's arrest, possibly due to the compounding factors increasing the risk of thrombosis. Herein, we discuss in detail the risk factors for LVT formation, its mechanism and management options. A review of the literature also shows that LVT formation in the acute phase of arrest, as seen in our patient, is rare. LEARNING POINTS: Left ventricular thrombus (LVT) formation occurs 3-14 days after myocardial infarction, but in the setting of concomitant ventricular fibrillation arrest, may occur within the first 24 hours.Risk factors for LVT formation include a large infarct, anterior/anterior apical infarction, decreased ejection fraction (particularly <30-35%), left ventricular aneurysm, and delayed time to revascularization.Although diagnosis is generally made on transthoracic echocardiography with intravenous contrast, cardiac MRI with contrast has better sensitivity and specificity.Treatment consists of anticoagulation with a vitamin K antagonist or heparin for 3-6 months with a repeat echocardiogram to confirm the thrombus has organized or resolved. Further trials are needed to assess the efficacy of direct oral anticoagulants.

A Rare Presentation of Sick Sinus Syndrome: Generalized Seizures.

Cardiac and neurological disorders are the main broad etiologies for loss of consciousness. Ictal bradycardia syndrome refers to epileptic discharges that profoundly disrupt normal cardiac rhythm, resulting in cardiogenic syncope during the ictal event. Convulsive syncope is a well-described phenomenon in both adults and children in which abrupt cerebral hypoperfusion leads to brief extensor stiffening and non-sustained myoclonus. Sick sinus syndrome or tachycardia bradycardia syndrome is a common cause of arrhythmias in the elderly secondary to sinus node dysfunction. We present a case of a 91-year-old male who presented with generalized seizure with associated bradyarrhythmias with telemetry showing sinus rhythm, followed by severe bradycardia, followed by Ventricular tachycardia, followed by an episode of asystole, which likely precipitated seizures as a result of cerebral hypoperfusion. The patient had a permanent dual-chamber pacemaker. He was discharged on antiepileptics as his EEG was abnormal, which might indicate an underlying predisposition.

Tricuspid Endocarditis: A Case Report and Comprehensive Literature Review.

Infective endocarditis is a multisystem disease. Tricuspid valve endocarditis is frequently seen in patients with intravenous (IV) drug users. Cavitating lung nodules predominantly in a peripheral location in IV drug users indicate the possibility of septic emboli. Large vegetation and persistent bacteremia with septic embolic phenomena are the most common indication for surgery. We present a case of a 62-year-old male with a history of IV drug use who presented with epigastric abdominal pain, pleuritic chest pain, and shortness of breath. CT chest showed cavitating lung nodules suggestive of septic pulmonary emboli. A transesophageal echocardiogram (TEE) showed tricuspid valve vegetation despite a normal transthoracic echocardiogram. The patient was treated with intravenous antibiotics. He was deemed a poor surgical candidate; therefore, he was transferred to a tertiary center for AngioVAC (AngioDynamics, Latham, New York).

Prothrombin G20210A Gene Mutation-Induced Recurrent Deep Vein Thrombosis and Pulmonary Embolism: Case Report and Literature Review.

Inherited thrombophilia is an important cause of venous thrombosis. The Factor V Leiden (FVL) is the most commonly encountered mutation, followed by the prothrombin G20210A gene mutation (PTM). The typical venous thrombotic events (VTEs) associated with PTM mutations are deep vein thrombosis (DVT) and pulmonary embolisms (PE). The PTM is inherited in an autosomal dominant pattern with variable penetrance. While heterozygous PTM mutations are more frequent and well documented in the literature, rare cases of homozygous PTM mutations are also reported. In this report, we discuss a 56-year-old male with a past medical history of homozygous prothrombin gene mutation (G20210A) who presented with an unprovoked DVT of the right lower extremity involving both the proximal and distal veins associated with multiple bilateral PEs. This case is unique in terms of the homozygous PTM inheritance, the age at which the patient presented (usually presentation is earlier in life), and the fact that he had a recurrence of both DVT and PE simultaneously.

Fever and Hyponatremia Unmasking Brugada Pattern Electrocardiogram in a Patient With SARS-CoV-2 Infection.

Brugada syndrome is an autosomal dominant genetic disorder that primarily affects myocardial sodium channels and has been associated with an increased risk of ventricular tachyarrhythmias and sudden cardiac death. Here, we report a case of a 58-year-old Hispanic male with a history significant for prior pulmonary tuberculosis infection who presented with pleuritic left-sided chest pain associated with body aches, productive cough, fevers, and chills and was found to be positive for SARS-CoV-2 by real-time reverse-transcription-polymerase chain reaction (rRT-PCR). Electrocardiogram (ECG, EKG) on presentation demonstrated a coved ST-segment elevation in V1-V2, suggesting Brugada pattern type 1 without evidence of ischemic changes. EKG changes normalized once fever and hyponatremia improved.

A 22-year-old COVID-19 positive male with no prior medical history presented to the emergency department with pulmonary infarction.

Rapidly growing evidence has now shown a high incidence of venous thrombosis in patients with severe acute respiratory syndrome secondary to novel coronavirus 2, a disease now named COVID-19. Accumulating case reports and series have also shown a higher prevalence of arterial thrombosis in these patients as well. Although the pathophysiology remains unknown but likely multifactorial - including endotheliitis from direct viral damage and an underlying hyper-inflammatory state, arterial and venous thrombosis occurrence does not appear to be linked with underlying classic risk factors for venous thromboembolism and may present in healthy patients without significant comorbidities. We present a case of a 22-year-old healthy patient with COVID-19 who developed a pulmonary embolism with a pulmonary infarction, a complication that results from arterial and venous thrombosis of the pulmonary vascular supply resulting in tissue necrosis.

A rare report of obstructive nephropathy induced hyponatremia.

Hyponatremia is a common finding in patients admitted to hospitals in the USA. There is a plethora of causes ranging from excessive diuretic use to volume overload from underlying heart failure or liver cirrhosis. The consequences of missing or mistreating the aforementioned diagnosis can lead to catastrophic outcomes. Here, we focus on a rare yet overlooked cause of hyponatremia: obstructive nephropathy. The causes of obstructive nephropathy in elderly patients are broad with neurogenic bladder being one of the common ones. Our patient is an elderly male who presented with hyponatremia in setting of urine retention post an orthopedic surgery.

Cocaine induced heart failure: report and literature review.

Heart failure is a complex clinical syndrome associated with high mortality and morbidity, creating a major public healthcare problem. It has a variety of etiologies, including substance abuse. Cocaine-induced cardiotoxicity is caused by direct effects of inhibition of sodium channels and indirect effects by inhibiting catecholamine uptake leading to increased sympathetic activity. Management is through the cessation of cocaine use and implantation of guideline-directed medical therapy for heart failure with the exception of beta-blockers as their safe usage is still controversial due to the risk of the unopposed alpha-adrenergic activity. Dexmedetomidine (Precedex) and Benzodiazepines (i.e., midazolam) are options for patients that demonstrate signs and symptoms of acute cocaine intoxication. If the actions of benzodiazepines fail to achieve hemodynamic stability, nitroglycerin may be used (especially in patients with cocaine-associated chest pain and hypertension). Cardiac transplantation is recommended for those who have demonstrated severe cardiovascular disease from cocaine. We present a 43-year-old male with a long-standing history of cocaine use who developed cardiomyopathy and severe acute decompensated heart failure found to have an ejection fraction of <20% admitted to the intensive care unit. He required inotropic support with milrinone and mechanical ventilation. He was later extubated and then discharged with an outpatient evaluation for a cardiac transplant.

Does Baseline Diuretics Use Affect Prognosis in Patients With COVID-19?

The rapid emergence of coronavirus disease 2019 (COVID-19) has become the biggest healthcare crisis of the last century, resulting in thousands of deaths worldwide. There have been studies that evaluated the role of angiotensin-converting enzyme (ACE) inhibitors (ACEi) and angiotensin receptor blockers (ARBs) in treating patients with COVID-19. However, the prior use of diuretics and their effect on mortality in this setting remains unknown. The aim of the study was to evaluate the effect of diuretics in patients admitted with COVID-19. The current study was conducted between March 15, 2020, and April 30, 2020, during the COVID-19 pandemic in three different hospitals in Northern New Jersey, USA. The primary outcome was survival or in-hospital mortality from COVID-19 from the day of admission. The secondary outcome was severe or non-severe illness from COVID-19. This retrospective study included a total of 313 patients with a median age of 61.3 ± 14.6 years. There was a total of 68 patients taking diuretics at home and 245 patients who were not taking diuretics. There was a total of 39 (57.35%) deaths in patients taking diuretics as compared to 93 (37.96%) deaths in patients not taking diuretics (p-value 0.0042). Also, 54 (79.41%) patients who took diuretics had severe COVID-19 illness as compared to 116 (47.35%) who did not take diuretics (p-value <.0001). However, after adjusting for the confounding factors, there was no difference in mortality or severity of illness in COVID-19 patients taking diuretics at the time of admission. In conclusion, there was no effect of the baseline use of diuretics in the prognosis of COVID-19.

A rare report of Rothia dentocariosa endocarditis.

Rothia species are gram positive, round to rod-shaped bacteria that are normally oral and respiratory tract flora. They were first isolated in 1967 from dental caries. We present a 69-year-old male with no risk factors for aforementioned bacteria however was found to have thickened anterior leaflet of the mitral valve with a small isoechoic lesion consistent with vegetation on Transthoracic echocardiogram. Blood cultures grew pan sensitive Rothia dentocariosa. Patient was treated with long-term antibiotics. This case adds to the limited number of cases of Rothia dentocariosa Endocarditis.

A Rare Complication of Rhabdomyolysis: Peripheral Neuropathy.

Rhabdomyolysis is a complex medical condition characterized by muscle necrosis and the release of intracellular components into the circulation. Although its most common cause is a direct traumatic injury, it can result from non-traumatic factors as well, including infection, toxins, and drugs. Serum creatine phosphokinase (CPK) levels are usually elevated in this condition and they correlate with the severity of the muscle damage (the higher the CPK peak, the greater the magnitude of muscle damage), although lower levels of CPK do not necessarily rule it out. The common complications associated with rhabdomyolysis include acute kidney injury, compartment syndrome, and, in rare cases, peripheral neuropathy. In this report, we present a case of a young patient, with a history of alcohol abuse, who presented with bilateral numbness of the feet post-immobilization and was subsequently found to have severe rhabdomyolysis.

COVID-Induced Spontaneous Pneumothoraxes: Case Series.

Severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2) is a communicable disease leading to COVID-19 infection that resulted in worldwide flooding of medical centers with the shortage of ventilators in some areas. The respiratory system is the most affected by the novel virus. Clinical manifestations are diverse in severity, with the most common symptoms including fever, chills, cough, and shortness of breath. The contributing factor to the morbidity and mortality associated with this virus is the rapid clinical deterioration as a result of a heightened inflammatory response, requiring supplemental oxygen. Pneumothorax is an unusual complication that may further worsen the hypoxia and require immediate intervention. We present a case series of two patients with no risk factors for pneumothorax besides recent COVID-19 infection, who were found to have spontaneous pneumothoraxes.

Invasive Pneumococcal Disease in a Patient With COVID-19: A Case Report.

The spread of the new severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19), has resulted in a global health pandemic and caused profound morbidity and mortality worldwide. The virus is known to cause severe hypoxemic respiratory failure and has been associated with extrapulmonary manifestations and end-organ dysfunction in the setting of extensive inflammatory response. Recently, the association between COVID-19 and pneumococcal pneumonia co-infection or superinfections has gained increasing interest. In this report, we present the case of a 58-year-old man with a past medical history significant for pulmonary tuberculosis, diagnosed over two decades ago, who presented with pleuritic chest pain, myalgia, intermittent fevers, chills, and productive cough and was found to have invasive pneumococcal disease and COVID-19. To our knowledge, this is the first reported case of invasive pneumococcal infection in a patient with COVID-19.

Naloxone induced pulmonary edema.

Naloxone-induced noncardiogenic pulmonary edema is a rare but reported entity that can occur following naloxone use in the reversal of opioid overdose. Proposed mechanisms include an adrenergic crisis secondary to catecholamine surge which causes more volume shift to pulmonary vasculature, subsequently leading to pulmonary edema. It appears to be more common when higher doses of naloxone are used. We present a case of a patient with opioid overdose came with altered mental status developed early features of pulmonary edema following the administration of multiple doses of naloxone. She responded well with the administration of diuretics and oxygen supplementation. Her oxygen requirements improved and didn't require mechanical ventilation.

An Atypical Presentation of Heroin Inhalation Induced Leukoencephalopathy (Chasing the Dragon).

Heroin leukoencephalopathy is associated with 'Chasing the dragon,' which is a heroin vapour inhalation method that is different from smoking or sniffing heroin. The clinical presentation ranges from mild to severe disease. Mild disease is characterized by inattentiveness and ataxia. In moderate diseases, extrapyramidal symptoms predominate, and finally, severe disease is characterized by generalized motor impairment, with death occurring in two-third of cases. We now report a rare presentation of the disease in a 60-year-old female with a past medical history of heroin abuse who presented to ED with signs and symptoms of confusion and restlessness. MRI brain without contrast showed diffuse symmetric increased intensity signals throughout the white matter. Electroencephalogram (EEG) revealed mild diffuse slowing with no lateralization. The patient was started on Vitamin E and was transferred to a rehab facility with following up neurology as an outpatient.

Unfortunate Outcomes in Patients With SARS-CoV-2 Superimposed on Pneumococcal Pneumonia.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the disease it causes, coronavirus disease 2019 (COVID-19), continue to have socioeconomic as well as health implications worldwide. The virus has already led to over 200,000 deaths in the United States alone. This is most likely secondary to quick respiratory deterioration seen in patients inflicted with the virus. In other words, the heightened inflammatory response leads to major organ system damage, which leads to rapid decompensation of the patient's clinical condition. Interestingly enough, some patients present with both the novel virus as well as a superimposed bacterial infection that further complicates the management of the disease. We present a case of a patient with a positive polymerase chain reaction (PCR) test for SARS-CoV-2 as well as a pneumococcal urine antigen; he was treated with both appropriate antibiotics as well as dexamethasone and remdesivir for pneumonia and novel virus, respectively. The patient's hypoxemia continued to worsen with appropriate means of oxygenation and eventually led to cardiac arrest.

Subacute COVID-19 Infection Presenting as Indolent Large Pericardial Effusion.

Reports of complications as a result of COVID-19 infection are emerging since the virus became a pandemic. Although not fully understood, reports show that the COVID-19 virus has shown acute pericardial involvement resulting from this infection. It can cause a wide range of manifestations from minimal effusion to large effusion with tamponade; however, there is little or no data on an indolent course of COVID-19 infection and its resulting manifestations. Here we describe a patient who had minimal disease symptoms for weeks, resulting in sizeable pericardial effusion formation.